Cross-Model Office Hours Session Primary Care First, Direct Contracting, and Kidney Care Choices December 19, 2019 Center for Medicare and Medicaid Innovation Centers for Medicare & Medicaid Services (CMS) 1
Presentation Overview • Overview of Primary Care First Model Options • Overview of Direct Contracting Model • Overview of Kidney Care Choices Model • Comparison of the Three Models • Q&A 2
Today’s Presenters • Pauline Lapin, Director, Seamless Care Models Group • Gabrielle Schechter, Primary Care First Lead • Emily Johnson, Primary Care First Seriously Ill Population Lead • Nicholas Minter, Director, Division of Advanced Primary Care • Perry Payne, Jr., Direct Contracting Model Co-Lead • Kate Blackwell, Kidney Care Models Lead 3
Audience Poll About which model(s) would you like to receive more information? a) Primary Care First b) Direct Contracting c) Kidney Care Choices d) All three models and their differences e) Unsure 4
Primary Care First Model Options 5
Introduction to Primary Care First (PCF) Primary Care First Goals Primary Care First Overview 5-year alternative payment model To reduce Medicare spending by 1 preventing avoidable inpatient hospital Offers greater flexibility , increased admissions transparency , and performance-based payments to participants To improve quality of care and access to care for all beneficiaries, particularly those 2 Payment options for practices that specialize with complex chronic conditions and serious in patients with complex chronic illness conditions and high need, seriously ill populations Fosters multi-payer alignment to provide practices with resources and incentives to enhance care for all patients, regardless of insurer Center for Medicare & Medicaid Innovation Primary Care First 6
PCF Payment Model Options The three Primary Care First payment model options accommodate for a continuum of providers that specialize in care for different patient populations. Option 1 Option 3 Option 2 PCF-General Component SIP Component Both PCF-General and SIP Components Focuses on advanced Promotes care for high-need, Allows practices to primary care practices seriously ill population participate in both the PCF- ready to assume financial (SIP) beneficiaries who lack a General and the SIP risk in exchange for primary care practitioner components of Primary Care reduced administrative and/or effective care First. burden and performance- coordination. based payments. Center for Medicare & Medicaid Innovation Primary Care First 7
Where PCF Will Be Offered in 2021 In 2021, Primary Care First will include 26 diverse regions : Current CPC+ Track 1 and 2 regions New regions added in Primary Care First Practices that are currently not participating in CPC+ but are located in a CPC+ region may be eligible to apply . Current CPC+ practices may participate in Primary Care First beginning in 2022. Center for Medicare & Medicaid Innovation Primary Care First 8
PCF Payment Model Option Eligibility Criteria The following criteria apply to practices who seek to participate in the general Primary Care First payment model or in both the general and SIP payment models. In the application, you will need to attest that you meet the following criteria: Include primary care practitioners (MD, DO, CNS, NP, PA) in good standing with CMS Provide health services to a minimum of 125 attributed Medicare beneficiaries Have primary care services account for at least 70% of the practices’ collective billing based on revenue Demonstrate experience with value-based payment arrangements Meet technology standards for electronic medical records and data exchange Provide a set of advanced primary care delivery capabilities Note: Practices participating in the SIP option will be subject to requirements discussed later in this presentation. Center for Medicare & Medicaid Innovation Primary Care First 9
PCF-General Model Option Payment Structure The Total Primary Care Payment is a hybrid payment that incentivizes advanced primary care while compensating practices that care for higher-risk patients for the increased level of care these patients typically need. Population-Based Payment Flat Primary Care Visit Fee Payment for service in or outside the office, Payment for in-person treatment that reduces adjusted for practices caring for higher risk billing and revenue cycle burden. populations. This base rate is the same for all $40.82 patients within a practice. per face-to-face encounter Payment Payment amount does n ot include c opayment or Practice Risk Group ( per beneficiary per geographic adjustment month*) Group 1: Average Hierarchical These payments allow practices to: $28 Condition Category (HCC) <1.2 • Easily predict payments for face-to-face care Group 2: Average HCC 1.2-1.5 $45 • Spend less time on billing and coding and Group 3: Average HCC 1.5-2.0 $100 more time with patients Group 4: Average HCC >2.0 $175 Payment will be reduced through calculating a “leakage adjustment” if beneficiaries seek primary care services outside the practice. * PBPM = Per Beneficiary Per Month Center for Medicare & Medicaid Innovation Primary Care First 10
Performance-Based Payment Adjustments 0% or -10% Did the practice meet the annual quality benchmarks (i.e., Quality Gateway)? No Performance Based Adjustment Note: this begins in year 2, based on year 1 performance* For year 2, PBA will be 0% or -10%, based Yes on AHU measure performance; years 3-5, PBA is automatically -10% Is practice performance above the 50 th percentile of the Yes national Acute Hospital Utilization (AHU) benchmark? No AHU Measure Performance TPCP Adjustment 1 Top 75% of PCF Top 10% of regional practices 34% practices on AHU? 11-20% of regional practices 27% 21-30% of regional practices 20% Regional No Yes 31-40% of regional practices 13% Adjustment 41-50% of regional practices 6.5% 51-75% of regional practices 0% -10% 0% Bottom 25% of regional practices -10% Adjustment Adjustment AHU Measure Performance TPCP Adjustment Does the practice’s AHU 2 Yes performance compared to Top 10% of regional practices 16% their performance last year Continuous 11-20% of regional practices 13% achieve the continuous 21-30% of regional practices 10% Improvement improvement target? 31-40% of regional practices 7% Adjustment 41-50% of regional practices 3.5% No 0% 51-75% of regional practices 3.5% Adjustment Bottom 25% of regional practices 3.5% * Performance-based adjustments in year 1 are based on performance on the AHU measure only and does not follow the above process. Center for Medicare & Medicaid Innovation Primary Care First 11
The SIP Model Option Aims to Transform Care for High-Need Patients Goals of SIP Model Option Offer a transitional high touch, intensive intervention to help stabilize SIP patients, promote relief from symptoms, pain, and stress, develop a care plan, and transition them to a provider who can take responsibility for their longer-term care needs Provide participating practices with additional financial resources to proactively engage SIP patients, address their intensive care needs, and help them achieve clinical stabilization and transition Transform high-need patient care into a replicable population-health initiative that is patient-centered and supports long-term chronic care management Center for Medicare & Medicaid Innovation Primary Care First 12
Overview of the SIP Practice Journey CMS Identifies SIP Patients: CMS uses claims data to identify beneficiaries in designated service areas. Practice seeks to make contact as soon as possible with interested SIP patients. Practice Engages New SIP Patients: Practice administers a face to face visit with patient within 60 days of identification. Practice Administers Care: Practice provides treatment and care coordination for attributed SIP patients. Practice receives payment adjustments based on quality of care. Patient Transitioned Out of SIP Payment Model Option: Practice transitions patient to long-term care setting or other eligible provider. Practice no longer receives SIP payment for transitioned patients. Center for Medicare & Medicaid Innovation Primary Care First 13
SIP Model Option Payment Structure SIP Payments Monthly professional One time payment population-based Flat visit fee Quality bonus for first visit payment $275 PBPM* base $40.82 base rate $325 $50 PBPM* rate minus a $50 per face-to-face (not geographically base rate encounter withhold † adjusted; inclusive of flat (geographically adjusted) (both geographically (begins after attribution; visit fee) geographically adjusted) adjusted) By default, SIP practices will receive up to 12 months ‡ of SIP payments per SIP patient, unless the beneficiary is transitioned or de-attributed sooner. Additional payments beyond 12 months may be allowed as appropriate on a per patient basis subject to CMS approval and practice eligibility. *PBPM = per beneficiary per month † SIP practices will have the opportunity to earn back the $50 PBPM base rate withhold from their SIP PBPM payment. ‡ Exceptions may apply. Please see the Request For Applications (RFA) for more details. Center for Medicare & Medicaid Innovation Primary Care First 14
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